Norfolk Island Ditching ATSB Report - ?
Sully is lucky he wasn’t flying for a politically-connected operator with poor regulatory oversight, to a neglected and dysfunctional remote territory through third world airspace in the wrong aircraft type for the mission. Had he been doing so, his inability to foresee and avoid the geese, and his failure to acknowledge his responsibility for the geese, would see him subjected to ongoing regulatory torture.
I think those putting Jame's actions as an equivalent to Sully's are doing Sully a disservice. Sully had an instant to sum up his situation and make a decision. He also had a good F/O with him. James had from ToD and the opportunity to hold to formulate a plan of action. His decision was ultimately to ditch after IMHO squandering the opportunity to get it on the runway. We are yet to find out how effective the F/O was or whether her inputs were ignored.
If you want to look at an equivalent situation then compare this accident with the Virgin 737 landing in Mildura. That is the same scenario where both crews ended up with no fuel, no alternatives and no options but to work out how to get the aircraft onto the ground safely. The crew at Mildura were also dealing with FG and not a 500' cloud base. The Captain and F/O of the Mildura incident are deserving of more accolade's than they have received.
I do agree though that CASA should have made a decision on Jame's status well before now and not continually make him jump through arbitrary hoops.
If you want to look at an equivalent situation then compare this accident with the Virgin 737 landing in Mildura. That is the same scenario where both crews ended up with no fuel, no alternatives and no options but to work out how to get the aircraft onto the ground safely. The crew at Mildura were also dealing with FG and not a 500' cloud base. The Captain and F/O of the Mildura incident are deserving of more accolade's than they have received.
I do agree though that CASA should have made a decision on Jame's status well before now and not continually make him jump through arbitrary hoops.
Wow - based on what?
If you want to look at an equivalent situation then compare this accident with the Virgin 737 landing in Mildura.
There are a couple of big differences between Mildura & Norfolk Is. Mildura is as flat as the s@#t carters hat. Basically any aircraft in a controlled descent will land in a survivable manner. And there's only scrub at the end of the runway if you over-run. Norfolk Is has rising terrain that might not be survivable if you tried the same trick, but landed early. And its not so friendly if you over-run.
And it was overwhelmingly likely that the fog was not on the ground at Mildura (the pilots had an expectation of breaking out of cloud below minima but before touch down - the Norfolk Is case didn't have this expectation) and the Mildura pilots had radio coms with people on the ground observing, both recently landed aircraft and others. I don't recall that being the case for Norfolk Is.
The wind at Mildura was dead calm. Once again, I don't really recall, but I'm not sure you would expect the same from Norfolk Is.
The fog at Mildura may have been thin enough to afford some view of the land or intimation of how thick the fog was. It occurred mid afternoon on a basically fine & sunny day.
The fog at Norfolk Is was probably sea fog. And it was night. The pilot would not have had even the faintest indication of where the ground was.
As I recall the pilot elected to ditch because he felt the survival prospects were better than a crash landing on the ground. At night in unforecast weather, I don't envy him that decision.
Maybe you need to look at the reports again OA because its obvious that your memory is not reliable. You make it sound as though landing a 737 off an RNAV approach with the cloud base and visibility well below the minima, is just a walk in the park.
Ever flown a 737? They also require a hard surface. If they had been just a small fraction off the hard stuff the outcome may have been very different. Plenty of jets have had gear collapse when colliding with runway lights.
The big difference in the weather is the Virgin crew had fog and the Norfolk crew did not. You might want to re-read the Mildura report. It was mid-morning and it was not a thin layer of fog.
The Norfolk crew had visibility below the cloud base and a Unicom operator on the ground who was giving them real time info on the weather.
Once again read the report. The Westwind was fitted with a radio altimeter. They used it to work out where the water was. They could also have used it to get closer to the ground and get below the cloud base having first set up a 3degree slope using the V/S function of the autopilot. I don't believe that ditching was the only course of action.
I do work in a well lit airconditioned office but its not that big, it does however travel at 3/4 the speed of sound.
Basically any aircraft in a controlled descent will land in a survivable manner.
The big difference in the weather is the Virgin crew had fog and the Norfolk crew did not. You might want to re-read the Mildura report. It was mid-morning and it was not a thin layer of fog.
The Norfolk crew had visibility below the cloud base and a Unicom operator on the ground who was giving them real time info on the weather.
The pilot would not have had even the faintest indication of where the ground was.
I do work in a well lit airconditioned office but its not that big, it does however travel at 3/4 the speed of sound.
BIG call, especially from a well lit air-conditioned office.
There are a couple of big differences between Mildura & Norfolk Is. Mildura is as flat as the s@#t carters hat. Basically any aircraft in a controlled descent will land in a survivable manner. And there's only scrub at the end of the runway if you over-run. Norfolk Is has rising terrain that might not be survivable if you tried the same trick, but landed early. And its not so friendly if you over-run.
And it was overwhelmingly likely that the fog was not on the ground at Mildura (the pilots had an expectation of breaking out of cloud below minima but before touch down - the Norfolk Is case didn't have this expectation) and the Mildura pilots had radio coms with people on the ground observing, both recently landed aircraft and others. I don't recall that being the case for Norfolk Is.
The wind at Mildura was dead calm. Once again, I don't really recall, but I'm not sure you would expect the same from Norfolk Is.
The fog at Mildura may have been thin enough to afford some view of the land or intimation of how thick the fog was. It occurred mid afternoon on a basically fine & sunny day.
The fog at Norfolk Is was probably sea fog. And it was night. The pilot would not have had even the faintest indication of where the ground was.
As I recall the pilot elected to ditch because he felt the survival prospects were better than a crash landing on the ground. At night in unforecast weather, I don't envy him that decision.
There are a couple of big differences between Mildura & Norfolk Is. Mildura is as flat as the s@#t carters hat. Basically any aircraft in a controlled descent will land in a survivable manner. And there's only scrub at the end of the runway if you over-run. Norfolk Is has rising terrain that might not be survivable if you tried the same trick, but landed early. And its not so friendly if you over-run.
And it was overwhelmingly likely that the fog was not on the ground at Mildura (the pilots had an expectation of breaking out of cloud below minima but before touch down - the Norfolk Is case didn't have this expectation) and the Mildura pilots had radio coms with people on the ground observing, both recently landed aircraft and others. I don't recall that being the case for Norfolk Is.
The wind at Mildura was dead calm. Once again, I don't really recall, but I'm not sure you would expect the same from Norfolk Is.
The fog at Mildura may have been thin enough to afford some view of the land or intimation of how thick the fog was. It occurred mid afternoon on a basically fine & sunny day.
The fog at Norfolk Is was probably sea fog. And it was night. The pilot would not have had even the faintest indication of where the ground was.
As I recall the pilot elected to ditch because he felt the survival prospects were better than a crash landing on the ground. At night in unforecast weather, I don't envy him that decision.
Join Date: Jul 2010
Location: sydney
Posts: 1,469
Likes: 0
Received 0 Likes
on
0 Posts
"Once again read the report. The Westwind was fitted with a radio altimeter. They used it to work out where the water was. They could also have used it to get closer to the ground and get below the cloud base having first set up a 3degree slope using the V/S function of the autopilot. I don't believe that ditching was the only course of action."
I can't agree with your suggestion Lefty. In your front office you have all the latest high tech gear to work with. When the Westward was built GPS was just a dream.The aircraft had very basic equipment. Round dials, no FMS an ancient basic trimble retrofitted GPS. You'll note from the ATSB report VOR approaches were flown, the GPS was not up to it. I can't imagine considering the circumstances the crew didn't bust minimums a tad, however Norfolk is notorious for wearing a cap of cloud when a warm moist airstream blows over it. Not unusual to get visual on an approach but be unable to land due to the strip being obscured by low cloud.The terrain around the airport is not flat, its cut by gullies, and lots of those famous Norfolk Island pines, so the slightest error would be disastrous, and night out there is very black. I think Dom chose the option most likely to be survivable.
I can't agree with your suggestion Lefty. In your front office you have all the latest high tech gear to work with. When the Westward was built GPS was just a dream.The aircraft had very basic equipment. Round dials, no FMS an ancient basic trimble retrofitted GPS. You'll note from the ATSB report VOR approaches were flown, the GPS was not up to it. I can't imagine considering the circumstances the crew didn't bust minimums a tad, however Norfolk is notorious for wearing a cap of cloud when a warm moist airstream blows over it. Not unusual to get visual on an approach but be unable to land due to the strip being obscured by low cloud.The terrain around the airport is not flat, its cut by gullies, and lots of those famous Norfolk Island pines, so the slightest error would be disastrous, and night out there is very black. I think Dom chose the option most likely to be survivable.
There's a small part of me that wonders whether the ditching was actually "chosen", or "planned".
The lack of mayday, or at least telling the NLK radio operator that they were indeed actually going to ditch and the location, makes me wonder.
Recovering the CVR soon after would have been valuable information for the report.
thorn bird what you are saying is absolutely correct and the situation that the crew found themselves in could not be blamed just on the PIC. Round dials, low cloud very few options, I did my time in GA so I know what it is like however the RAlt was the one bit of equipment that I think could have been used to better effect than to work out where the water was. The cloud base was OVC 002 at the time of arrival. 200' is a CAT 1 minima so for a small jet continuing to 100' on a 3degree slope (which the approach chart states) will give you a good chance of seeing the runway. As I said before I don't think that ditching was the only option.
P.S What have you done with my old sparring partner Gobbledock? He seems to have disappeared.
P.S What have you done with my old sparring partner Gobbledock? He seems to have disappeared.
I’d love to re-read the report but the ATSB has removed it from the website. The original report is so old, it was at least 3 laptops ago for me and I’ve long since discarded the paper copies that I worked from at the time.
Not the behaviour one expects from a body such as the ATSB with impartial transparent processes.
I’m sure this is an attempt by the ATSB to frustrate comparisons of the last report with the soon to be published (??) new report. But equally, I trust that the pprune community will have saved copies that we can use at the time.
I was in the Ansett 737 SIM recently and we landed it in zero visibility hand flying using the ILS. But it occurs to me that airline pilots using SIMS for recurrent training get to do some things beyond the normal limits like that.
On the other hand, a relatively young charter pilot’s experience is likely to only ever have involved doing training in real aircraft doing real approaches and being smacked every time he broke minima by so much as 50 ft.
I still reckon it’s a tough call to say he didn’t make an optimal decision. Everyone survived. I’d rather focus on the information upon which he relied to get to that point.
In the Sullenberger accident, I believe they put a number of pilots in SIMS to see if they did better. It would be an interesting excercise to see what they would do given the same met information and ATC directions. I’ll bet the ATSB don’t do it.
Not the behaviour one expects from a body such as the ATSB with impartial transparent processes.
I’m sure this is an attempt by the ATSB to frustrate comparisons of the last report with the soon to be published (??) new report. But equally, I trust that the pprune community will have saved copies that we can use at the time.
I was in the Ansett 737 SIM recently and we landed it in zero visibility hand flying using the ILS. But it occurs to me that airline pilots using SIMS for recurrent training get to do some things beyond the normal limits like that.
On the other hand, a relatively young charter pilot’s experience is likely to only ever have involved doing training in real aircraft doing real approaches and being smacked every time he broke minima by so much as 50 ft.
I still reckon it’s a tough call to say he didn’t make an optimal decision. Everyone survived. I’d rather focus on the information upon which he relied to get to that point.
In the Sullenberger accident, I believe they put a number of pilots in SIMS to see if they did better. It would be an interesting excercise to see what they would do given the same met information and ATC directions. I’ll bet the ATSB don’t do it.
Love reading all the bull**** from armchair experts. The crew stated that hitting the water came as a shock and the viz zero at impact. The weather on Norfolk was pelting down with low sub minima scudding windy conditions. There are houses in the airport vicinity and very tall Norfolk pines.. right or wrong they all survived and I seriously doubt many of you who so easily attack him could have pulled off the same magic.
Join Date: Feb 2010
Location: sydney
Posts: 44
Likes: 0
Received 0 Likes
on
0 Posts
The CVR will tell all I expect.
Back around 1998 or 99, I recall an RPT operator in a Chieftain going to Norfolk and arrived not long before the end of daylight, to conditions not too dissimilar to VH-NGA, and which were deteriorating. The aircraft made several unsuccessful approaches and on the final one used the ARO’s vehicle at the threshold with its flashing light as an indication of where the threshold was. Aircraft subsequently landed in conditions of approximately 200m vis and 100ft cloud base. The pilot did a fantastic job in getting the aircraft on the ground in one piece (but probably shouldn’t have been there in the first place as an alternate requirement existed on the TAF - which was changed from a Tempo enroute & the PA31 was not capable of proceeding to Norfolk and then to an alternate). The PA31 is not a Westwind I know but I offer this as another example of how a similar incident was dealt with.
The only other comment I would like to make regarding the original accident report was that in the years preceding this accident, the ATSB were utilising the Reason Model, which in effect, was identifying all the pieces of “Swiss Cheese” i.e. the defences in place that failed to prevent an accident or serious incident. In virtually every accident, the pilot(s) is always the last piece of Swiss Cheese i.e. the last line of defence. Although the Reason Model doesn’t appear to have been used in this particular accident investigation, it is quite clear to me that the ATSB focussed its investigation primarily on that last piece of cheese at the expense of many other very relevant pieces which I would have thought should include at least the Operator (supervision, procedures etc), Regulator (adequate oversight etc), ASA etc. While I’m not usually a believer in conspiracies, it does look like there’s been political interference at play considering who was on the parent company’s board...
As far as I’m concerned the pilot has been punished enough (although the co-pilot does not seem to have had any adverse treatment whatsoever).
VH-MLE
The only other comment I would like to make regarding the original accident report was that in the years preceding this accident, the ATSB were utilising the Reason Model, which in effect, was identifying all the pieces of “Swiss Cheese” i.e. the defences in place that failed to prevent an accident or serious incident. In virtually every accident, the pilot(s) is always the last piece of Swiss Cheese i.e. the last line of defence. Although the Reason Model doesn’t appear to have been used in this particular accident investigation, it is quite clear to me that the ATSB focussed its investigation primarily on that last piece of cheese at the expense of many other very relevant pieces which I would have thought should include at least the Operator (supervision, procedures etc), Regulator (adequate oversight etc), ASA etc. While I’m not usually a believer in conspiracies, it does look like there’s been political interference at play considering who was on the parent company’s board...
As far as I’m concerned the pilot has been punished enough (although the co-pilot does not seem to have had any adverse treatment whatsoever).
VH-MLE
Well, it will be released in a week.
https://www.atsb.gov.au/publications...r/ao-2009-072/
Updated: 16 November 2017
The investigation report has now been approved by the Commission and finalised. As part of our pre-release process, an advanced copy of the report has been sent to all Directly Involved Parties under the provisions of Section 26(1) of the Transport Safety Investigation Act 2003 (the Act).
The public release of the final report will be made available on the ATSB’s website at 10.30am on 23 November 2017 in accordance with subsection 25(1) of the Act.
The investigation report has now been approved by the Commission and finalised. As part of our pre-release process, an advanced copy of the report has been sent to all Directly Involved Parties under the provisions of Section 26(1) of the Transport Safety Investigation Act 2003 (the Act).
The public release of the final report will be made available on the ATSB’s website at 10.30am on 23 November 2017 in accordance with subsection 25(1) of the Act.
Originally Posted by lookleft
Based on the report. They did not hold and just conducted several approaches to the chart minima and conducting a subsequent go-around on each occasion. The cloud base was about 500' and the chart minima was about 700'.
TAF amended at 0958
SPECI YSNF 181000Z AUTO 18009KT 4500 OVC002 19/19 Q1013 RMK RF00.2/001.0
Ditching at Norfolk Island at 1026.
SPECI YSNF 181030Z AUTO 16009KT 3000 OVC002 19/18 Q1013 RMK RF00.4/002.4